Asthma in Women, Asthma in Pregnancy (cont.)

Although open windows can allow pollens and other triggers into the house,
there may be a trigger in the house, such as smoke, that necessitates opening a
window.

Pets with fur should be kept out of the bedroom. If pets
are to be kept in the household, they should be bathed twice weekly to reduce
the amount of allergens (substances with potential to cause asthma or allergy
symptoms). An asthmatic may be allergic not only to the animal itself but also
to danders or
pollens that the pet carries in from the outside.

Following these recommendations down the last detail would be unrealistic, of
course, but at least they are guidelines. Additionally, perhaps some of the
chores that are associated with asthma triggers can be done when the person with
asthma is out of the house.

Although these recommendations
have not been proven to be totally effective (indeed some research finds these
measures to not be helpful at all), they are inexpensive and without side
effects compared to medications, and therefore are considered standard measures
for consideration by every asthma. Physicians generally counsel all asthmatic
patients regarding these measures, if they are found to be allergic by skin or blood testing.

Do Filters Help?

High-energy particulate
absorption (HEPA) filters have recently gained in
popularity. They are filters that remove many allergens from the air. There is
not complete proof that these filters should be used by everyone with asthma.

Key point:
The risk of asthma that is not controlled in pregnancy is
greater than the risk of using medication! The baby needs oxygen!

There are several kinds
of asthma medications. Generally, they come in two categories: fast-acting
medication (called rescue medication, used for immediate relief of symptoms) and
medication (maintenance therapy) that is used regularly
each day to prevent the need for the rescue medication. Preventive asthma
medications are not addictive, even when used for years!

People who really know how to use their asthma medications
and how to alter them with changes in their asthma symptoms not only feel better
about their asthma, but research is also beginning to prove that they also have
more healthy days than people who just visit the doctor at regular intervals.

Allergy shots (Immunotherapy) is effective for most people with hayfever. It
clearly also helps some people with asthma as well. Those asthmatics likely to
respond are children, highly allergic individuals and those with poorly
controlled hayfever or sinusitis.

The latest
treatment recommendations are based on the National Asthma Education and
Prevention Program's Report of the Second Expert Panel on the Guidelines for the
Diagnosis and Management of Asthma, published in 1997 (2). These treatment
guidelines, sponsored by the National Heart, Lung, and Blood Institute, give
more emphasis to the use of anti-inflammatory medications, and to possible
prevention of asthma, than did prior guidelines. The plan is called a "step
approach". This means that if one medication does not do the job, the dose or
frequency of doses is raised and other medication is added, and then as the
asthma is better controlled, the medications are decreased in a "step down". The
2 generally categories of medication are controller medications (maintenance
medications) and reliever medications (rescue medications).

For acute, meaning immediate, relief, medication that dilates (opens) the
airways is used. These medications, b-agonists, are usually taken in inhaled
forms, called metered dose inhalers (MDI's). Examples include albuterol and
metaproterenol. There are few side effects of these inhaled bronchodilator
medications. Some people may get palpitations, a sense of the heart beating
fast, or a sense of feeling "jittery". Some people seem to be more sensitive
to those side effects than others. Some people may notice this type of side
effect only occur at high doses of the medications. This quick relief medicine
should always be carried in case of unexpected need. Often people will be told
to keep these medications scattered in easy-to-find locations, like purses or
pockets, desk at work, or glove compartment.

Because asthma's underlying cause is thought to be inflammation (swelling
in the airways), anti-inflammatory therapy is the basis for prevention of acute
attacks (exacerbations). Daily preventive (maintenance) medication may be needed
if people cough, wheeze, or have chest tightness more than once weekly, if
night-time asthma wakes them up, if they have many asthma attacks, or if they
are using asthma rescue medication daily.

Therapy consists of
inhaled corticosteroids. Corticosteroids are drugs that if taken orally can have
significant side effects over the long-term, although these are not the same
drugs that became popular with body-builders. Therefore, inhaled forms of the
corticosteroids were developed in the form of MDI's. Examples include
fluticasone, beclomethasone, and budesonide. Although it is known which of these
is the most potent compared to the others (fluticasone), studies actually
comparing use of the medications are not very numerous. Steroids are
anti-inflammatory, so that they decrease airway swelling, lessen mucus, and
decrease the overly active "twitchy" problem in the airways.

There are no immediate side
effects of steroid MDI's that a person would
feel. Thrush, a whitish yeast infection
on the tongue, can occur as a side effect, and is minimized by rinsing out the
mouth with water after use and using a "spacer" device that attaches to the
inhaler. Spacers are available by prescription and help the medication get into
the lungs instead of depositing in the mouth. Based on the fact that use of oral
steroids can put people at risk of osteoporosis (brittle bones), there is some concern that inhaled steroids might
also decrease bone density, and as a consequence cause fractures later on. The
research so far is regarding this possible side effect is controversial, but
suggests that this possible side effect is greater with higher potency or higher
doses of inhaled steroids. Hopefully the exact degree of risk with different
preparations and doses will become clearer in the future. For the time being,
consulting with a physician that adequate calcium intake, vitamin D intake, and
exercise are being achieved for bone health is a wise idea.

The safest and most effective asthma treatment is inhaled medication,
including corticosteroids

Salmeterol is a relatively new medication that is a longer-acting b-agonist.
It is often used in people frequently needing b-agonists, in hopes of decreasing
the need for short-acting rescue medications. It is also sometimes added to
inhaled corticosteroids to improve asthma control or to reduce the dosage of
these inhaled corticosteroids needed for asthma control. Some research has shown
that asthma control in people already using steroid MDI's is improved moreso
by addition of salmeterol than by raising the dose of the steroid MDI. Of
course, this means using two inhalers instead of one inhaler. Salmeterol is
sometimes used as a long-term medication to prevent exercise-induced asthma, but
there is some research showing that its effectiveness when used for this
specific reason may slightly decrease gradually with time.

Cromolyn is a medication that has been around for a long time. It is one of
the safest medications of all available prescription medications, but it is not
very potent. It is used sometimes as maintenance therapy to prevent acute asthma
attacks, but it does not help during an acute attack.

Theophylline is an older asthma medication that is taken in pill-form. It
acts as a bronchodilator and seems to be especially helpful for people with
night-time decrease in lung function that commonly occurs in people with asthma.
It's use at night has largely been replace by the long- acting bronchodilator
salmeterol.

Use of theophylline requires blood
tests to determine blood levels of the medication as part of its safety
monitoring. It also has potential side effects, including nausea, increased
heart rate (experienced as palpitations),
irritability, and insomnia, among others. These side effects are similar to
those of caffeine. It also has potential for
many drug interactions, meaning it can affect the use of other medicines used at
the same time for other conditions, and vice-versa. Acute illnesses can also
alter its metabolism (how
the drug acts in the body and is eliminated from the body). For these reasons it
is infrequently used in asthma treatment. Newer medications particularly
inhalers like salmeterol are more effective and have less side effects.

A new class of maintenance medicines has emerged in the last several years.
In fact, they were the first new treatment to be approved in 20 years for
chronic asthma They are pills that act to reduce the production of, or the
action of, chemicals that the body itself makes during an asthma attack. These
chemicals called leukotrienes are produced by the inflamed airway, and narrow
the airways. These medications are called anti-leukotrienes. Depending on the
medication, they either stop the production of the trouble-making leukotrienes,
or else block the harmful action of the leukotrienes. It is hoped that they can
reduce the need for, or possibly the dose of, other asthma medications. These
medications include zafirlukast, montelukast, and zileuton. These
antileukotriene drugs directly block bronchoconstriction but are also
anti-inflammatory, whereas corticosteroids are only anti-inflammatory. These
medications have not been compared to each other, so it is not known if one has
any clear advantage over the others. Most of the benefit of these drugs is seen
within 2-4 weeks of starting the medication (A), and they generally reduce the
need for rescue therapy by 1/3rd (A). They help decrease nighttime asthma
symptoms as well (A).

When
compared head-to-head, the anti-leukotrienes and the inhaled steroids each help
certain lung function tests, quality of life, night-time awakenings,
numbers of asthma-control days, and asthma attacks. The two medications were
each helpful as controller medications for chronic asthma. Both drugs were very
well tolerated in terms of side effects. Other research has added anti-leukotrienes
to high doses of inhaled steroids in chronic asthma patients. Patients who did
have the anti-leukotriene added had a better chance of successfully reducing the
inhaled steroid dose than those who did not add an anti-leukotriene to their
inhaled corticosteroids. The anti-leukotrienes are not yet felt to be useful in
severe asthma, and many people with milder asthma are already controlled and
happy on either intermittent rescue medication or chronic inhaled corticosteroid
MDI's with only occasional need for rescue medication.

It might be that these medications if used regularly for
many weeks, are good at preventing exercise-induced asthma, as is being shown in
recent research, and that they may help a certain type of asthma called
aspirin-sensitive asthma. However, there are many issues that have come up
regarding these medications; people may find using MDI's more convenient that
taking these pills, MDI's in low doses have minimal absorption compared to pills
thus possibly less potential for side effects, and long-term studies of these
pills are not available yet. Also, zileuton has potential to cause abnormal
liver function test in the blood, so that all people taking this medication will
need liver test monitoring via blood tests at intervals, especially in the first
3 months of use. Therefore their precise role is still being determined,
especially in the long-term. Specifically, we need long-term safety and
effectiveness data,
and need to clearly establish what specific group of asthmatics will benefit
most from them. Probably for the time being, in real daily practice while we
await research, their use is considered in the following mild to moderate
asthmatics: those with less than optimal benefit from inhaled steroid, those
with aspirin-sensitive asthma, and those needing high doses of inhaled or oral
steroids.

In summary, then, these anti-leukotrienes are a good choice for people with
aspirin-induced asthma, and they can improve lung function in those with chronic
asthma by decreasing: need for rescue medications, asthma symptoms, frequency of
attacks needing oral steroid pills, and dose of inhaled steroids needed for
long-term control. They are also useful for exercise-induced asthma.

In very severe asthma, daily oral
corticosteroids (or steroids) may be necessary. These have many potential side
effects, so that physicians generally explore every single other reasonable
alternative before starting oral corticosteroids. They also try to use other
medications to reduce the necessary dose of these steroid pills. These oral
steroids are not the same medications used (abused) by body builders. They can
be life-saving drugs for people with severe asthma, and they are used in the
lowest dose possible in order to reduce possible side effects. When people are
admitted to the hospital having an acute asthma attack that cannot be terminated
with inhaled medications, they are often given corticosteroids in intravenous
form (into the veins in their arms) for a
short time to bring the attack under control, after which the medication is
converted back to oral and inhaled forms. The most frequent use for oral
steroids is a short course (5-10 days). This is the most effective way to control
acute asthma attacks or poorly controlled chronic asthma which are not
responding to inhaled medications.

The Office of Women's Health of
the Federal Drug Administration has a section called Women's Health: Take Time
to Care (7), the aim of which is to make women aware of safe medication use.
Women are the principal users of medications and who often have to administer
medication to family members.

Frequent review
of the technique of using inhaled medications is very helpful. First, the cap
should be removed. The inhaler should be shaken before use. Inhalation of the
medication should be done with the head tilted back, with the mouth about 1 inch
away from the inhaler. Before inhaling the medication,
patients should exhale (breathe out) completely. The medication is inhaled
slowly, over 3 to 5 seconds. Then breath should be held for 10 seconds so the
medication will get to and stay in the lungs. When prescribed two puffs at one
time, a few seconds should go by between puffs. People having difficulty using
the inhaler with a spacer (see below) should discuss the problem with their
physician. The inhaler and its cap should be cleaned in warm water each day. The
mouthpiece should also be washed occasionally with mild dishwashing detergent
and water. After being washed each time, the parts should be allowed to dry
before storage.

Spacers are devices used to increase the amount of medicine actually reaching
the lungs. They also help to avoid the thrush (see above) that can happen as a
side effect of the inhaled corticosteroids. Rinsing out the mouth after each use
of inhaled corticosteroids will also help minimize thrush. The spacer can
minimize the amount of medication that just stays on the tongue, so that the
medicine will go where it belongs, in the lungs. The spacer holds the medicine
so it can be inhaled slowly, and helps to minimize cough that results
occasionally from using an MDI.

If a woman uses her quick-relief (rescue) medication more than 3 times
weekly, chances are she should be on a daily long-term therapy medication to
decrease inflammation over the long-term. Using inhaled steroids early in asthma's
course may not only control asthma better but also make lung function normal.

People who use both inhaled steroids and rescue inhaled bronchodilators
should first use the bronchodilator to open the airways, to better allow the
corticosteroid that they use next to reach the lungs.

All women with asthma need to have education regarding what to expect from
their asthma as well as what to expect from their asthma medications. Education
is critical, and every woman's plan is individualized so that a woman should
be able to do her usual activities. Women should expect or request a written
plan from a treating physician which includes expected length of treatment with
each medication, when to expect each medication's effect to be felt, and what
to do if a dose is missed.

To see how much medication is left in an MDI canister can be difficult.
However, putting it in a sink full of water can give an idea of how empty the
canister is. A canister floated in this way will float completely to the top
when it is empty and sink all the way to the bottom when full. It will be
floating vertically when half full, and sink vertically when mostly full.

The older form of the inhaled asthma medications is slowly being phased out.
This is because the older MDI's have chlorofluorocarbons (CFC's). These CFC's
decrease the amount of ozone in the ozone layer around the earth and are
therefore thought to have a harmful effect on the environment. Therefore, the
medications are gradually being put into forms that do not contain CFC's. Some
of these forms are already available. New formulas, such as dry powder inhalers,
are being substituted for the older CFC MDI medications, with the goal of one
day having only non-CFC-containing inhalers.

Further information on how to use inhalers probably and regarding monitoring
and treatment of asthma are available from the NHLBI (2).

Doctors usually give out a written set of instructions that describes the
individual treatment plan. The partner in the treatment plan, the woman with
asthma is expected to keep an accurate diary of her symptoms. She needs to go
the doctor at least a few times a year, even if she feels okay and thinks her
asthma is doing fine.

Also, if she has moderate or severe persistent asthma, or if she ever
develops severe asthma attacks regardless of the type of asthma she has, she
should monitor her peak expiratory flow, sometimes called simply peak flow. The
highest of 3 trials using a peak flow meter is the person's peak flow. Peak
flow monitoring helps both the woman and the physician know how her asthma is
really doing, and may help the woman be more aware of how her symptoms relate to
her lung function at any given time. The NIH has information on performing peak
flow monitoring. (2)

Technically speaking, asthma is no longer defined as mild, moderate, or
severe. Instead, more specific categories are now used, and doctors base their
treatments on them. Asthma classification categories are now mild intermittent,
mild persistent, moderate persistent, and severe persistent. Within each one of
these categories, attacks can be mild, moderate, or severe.

Asthma course
can get better, worsen, or stay the same during pregnancy, in unpredictable
fashion. Risk of using asthma medications during pregnancy is much lower than
the risk of bad outcomes due to uncontrolled asthma. Oxygen supply for the fetus
relies on proper control of a pregnant woman's asthma. Asthma is
to be treated as aggressively in pregnant as in nonpregnant women, with both
rescue and preventive medications. Although women are understandably worried
about using any medications during pregnancy, use of asthma medications during
pregnancy clearly bring about less in the way of bad outcomes than does leaving
asthma uncontrolled during pregnancy.

References, and for further information or help, Government initiatives and
national organizations devoted to asthma.

(1) The Global Initiative for Asthma is a project of the
National Heart, Lung, and Blood Institute, National Institutes of Health, and the World Health
Organization. Its purpose is to increase public awareness of asthma, support
asthma research, decrease its harmful toll on the U.S., and improve its
management. Information is at www.ginasthma.com/home/home.html

(2) National Heart, Lung, and Blood Institute is at www.nhlbi.nih.gov, and
their specific asthma information for the public is at www.nhlbi.nih.gov/health/public/lung/index.htm,
1-301-251-1222